Contributions to the Practice of Ethics Consultation

While the general purpose of clinical ethics consultation is to help resolve ethical questions or dilemmas in patient care, persons who perform ethics consultation come from diverse professional backgrounds and do not share the same problemsolving methods or theoretical assumptions. This diversity has left its stamp on the way clinical ethics consultation is performed, and has profound implications not only for the practice of clinical ethics consultation but also for the training of its practitioners.

Despite this diversity, a common ground can be seen in the shared goal of identifying an ethically supportable solution to a clinical ethical question or dilemma, and in a recognition that the process of arriving at a solution requires knowledge of law, ethics, medicine, psychosocial issues, and at times, religion.

The legal tradition has influenced clinical ethics consultation by placing emphasis on rights and on formal mechanisms of decision making and arbitration, such as due process. The protection and nurturing of individual rights are central to this style (Wolf). Strict adherence to this style, however, may encourage adversarial rather than collaborative or nurturing relationships between patients and healthcare professionals (Agich and Youngner).

The medical tradition has contributed methods, assumptions, and traditions of clinical practice: a combination of technical knowledge and clinical experience (La Puma and Toulmin). Some argue that physicians are best suited to provide clinical ethics consultation because (1) their advice will be easily accepted by their medical colleagues, because they have clinical experience and speak the same language; and (2) only physicians can understand the ethos of physician-patient relationships. Critics caution that because they are "insiders," physicians may promote the values of medicine rather than those of their patients or the larger community. They argue that the ethics consultant should serve as a bridge between medical and other values, and cannot function properly from a position entirely within medicine (Glover et al.; Churchill).

Moral philosophy has offered three major approaches to clinical ethics consultation. The first is principle-based ethics, which argues that the answer to a given ethical question or dilemma may be discovered by applying the correct ethical theory (e.g., utilitarianism) or principle (e.g., autonomy) to the case. The second is virtue ethics, which emphasizes that the possession of certain virtues (e.g., honesty, loyalty, compassion) is essential to sound ethical decision making. The third is a case-based or casuistic ethic, which holds that by examining the particulars of a given case and comparing them with similar cases, a moral maxim that applies to the case can be discovered. An advantage of casuistry is that it sues a decision-making method already employed by clinicians (Jonsen and Toulmin). Casuistry relies upon teachable medical moral maxims that build upon experience. Because casuistry is not principle-based, it has been criticized as "situational," that is, pragmatically driven to solve individual problems without reference to a broader moral framework.

While principle-based clinical ethics reasoning has the advantage of providing a consistent moral reference point, its principles are necessarily abstract, often conflict with each other, and may create a rigid paradigm that is insensitive to differences in specific cases.

Theology and religion contribute to clinical ethics consultation by recognizing that specific religious positions may either facilitate the resolution of an ethical question or contribute to its intensity. For example, the Jehovah's Witness position on blood transfusions can create serious ethical dilemmas in the case of a Jehovah's Witness patient who is in urgent need of extensive, lifesaving surgery but refuses blood. One of the disadvantages of this perspective is that many physicians are suspicious of or even hostile to religious or theological interpretations of medical problems. However, insight into the religious morality of patients, family members, and healthcare professionals is useful in establishing communication and reaching understanding among physicians, patients, and family members.

Consultation liaison psychiatry and clinical psychology have influenced clinical ethics consultation by addressing dynamic and interpersonal elements of clinical ethics cases. This style involves using insight into the motivations and values of those involved in the ethics case to resolve conflicts among decision makers. The goal is to produce a consensus or compromise solution rather than to evoke rights language, ethical principles, or religious codes. A disadvantage of this approach is that a compromise solution is not always a just one. Its strength is that it skillfully manages confrontation and addresses the emotional needs of the participants.

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